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I understand that I am responsible for paying my deductible or co-pay where applicable. Signature Date I authorize SOPCC to release information to Practice Management Solutions for the purposes of billing and I understand I am respobilbe to pay the fees incurred for this service. This section must be completed by the Clinician BEFORE paperwork is processed Clinician Location Estimated amount due at time of service co-pay and/or deductible Reduced fee non-insurance only Write off Diagnosis 1...
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